1275034597 NPI number — KILLEEN MODERN DENTISTRY, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275034597 NPI number — KILLEEN MODERN DENTISTRY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KILLEEN MODERN DENTISTRY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275034597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 920050
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75392-0050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-845-8500
Provider Business Mailing Address Fax Number:
303-952-0892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 W STAN SCHLUETER LOOP
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
KILLEEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-870-9209
Provider Business Practice Location Address Fax Number:
254-870-9886
Provider Enumeration Date:
02/22/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HUANG
Authorized Official First Name:
ANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER DENTIST
Authorized Official Telephone Number:
254-870-9209

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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